Most recent update- Clinics of north america

1. Prevention and management of
complications of pancreatic surgery
Dr. Zeeshan Rahman

2. Introduction
 Mortality of pancreatic surgery has decreased:
- 33% in Whipple’s reports to 5 % in high volume
centres.
 Morbidity – 35 – 50 %
 The three most common complications:
- Delayed gastric emptying (14%)
- Wound infection (7%)
- Pancreatic fistula (5%)

4. Importance of hospital volume on outcome
 There was a 3-4 fold increase in mortality in low
volume centres compared to high volume ones.
 A recent single institution study reports that higher
surgeon volume is associated with shorter operating
time, less intraoperative blood loss and higher lymph
node harvest.

5. Post-pancreatectomy hemorrhage
 Incidence : 8%
 Mortality : 11% - 38%
 Definition developed by International Study Group of
Pancreatic Surgery (ISGPS)
- Intraoperatively
- Early postoperative period (<24 hours)
- Late postoperative period (>24 hours)

6. Intra-operative hemorrhage
 Usually occurs in the event of aberrant vasculature
Common variations:
- Replaced right hepatic artery (11 – 21 %)
- Replaced left hepatic artery (4 – 10 %)
- Accessory right or left hepatic artery (<1% - 8%)
- Coeliac artery stenosis (2% - 8%)

7. To avoid intraoperative hemorrhage

8. Measures to be taken
 Direct pressure over bleeding site
 Aberrant vessels may need to be reconstructed or
reanastomosed to an alternate vessel
 Doppler ultrasonography may identify aberrant
vessels
 Venous injuries may require a venoplasty or a patch
venorrhapy

9.  In exsanguating uncontrollable hemorrhage – portal
vein ligation has been described with a potential to
survive when accompanied with a second look
laparotomy
 GOAL
- Allow ICU resucsitation to reverse accompanying
hypothermia, coagulopathy and acidosis
 Other techniques:
- External drainage, packing, stapled bowel closure
and rapid abdominal closure

10. Management of Early and Late PPH
 Early PPH : Usually a technical factor
If severe – prompt re-laparotomy required
 Late PPH : result of postoperative complications
- Fistula
- Anastomotic ulceration
- Pseudoaneurysm formation

11. PPH once apparent – what to do??
 Evaluation depending upon hemodynamic status of
patient and site of bleed ( intraluminal versus
extraluminal)
 Endoscopy, angiography, CT scan and reoperation.

13. Pancreatic fistula
 Incidence : 30 %
 Difference from a leak
Fistula : Abnormal communication between two
epithelial surfaces
Leak: An abnormal escape of fluid through an orifice or
opening
POPF : Occurs with leakage of amylase rich fluid from
the transection margin of the gland or pancreatico-
enteric anastomoses

14.  Classified by ISGPF into grade A, B and C.
 Grade A fistulas : Biochemical only (not clinically
relevant)
 Grade B fistulas: Requiring further evaluation and
management with antibiotics, nutritional support,
octreotide or percutaneous drainage
 Grade C fistulas: Requiring surgery

16. Risk stratification
 Prevention of POPF relates to risk stratification
according to disease related, patient related and
operative risk factors.
DISEASE RELATED
 A soft gland or diagnosis of ampullary, duodenal,
cystic or islet cell pathology increases risk by 10 fold.
 Small MPD (<3mm) increases risk of POPF

17.  PATIENT RELATED
- Older age, male gender, IHD, jaundice and low
creatinine clearance – predictors of POPF
- Neoadjuvant therapy reduce risk of POPF
 OPERATIVE RISK FACTORS
- Blood loss > 1000 ml
- Duration of operating time
- Incidence of POPF same after distal and central
pancreatectomy ( Clinical course in distal resection is
milder)

18. Preventive measures
 Technique of suturing :
- Duct to mucosa versus invagination technique:

21.  Type of anastomoses:
- Pancreatico-gastrostomy is advantageous compared
to pancreatico- jejunostomy
(a) Thickness and blood supply of gastric wall.
(b) Proximity to pancreas
(c) Incomplete activation of pancreatic enzymes in
presence of gastric secretions

22. Why do pancreatico jejunosotomy ?
 Yeo et al demostrated no difference in fistula rate in
a prospective randomised controlled trial comparing
pancreaticogastrostomy to pancreaticojejunosotomy.
 Fistula rate was 12 % each.
 In summary a successful pancreatico-enteric
anastomoses required:
- Tension free anastomoses
- Preserved bloos supply of pancreatic remnant
- Unobstructed flow from pancreas to GI tract

23. Stapled versus sutured pancreatic remnant
 No clear advantage of one technique over another
 Either approach is acceptable
ROLE OF OCTREOTIDE
- Studies of octreotide are conflicting
- Some authors have found its effectiveness in distal
or local resection but not for
pancreaticoduodenectomies
- Benefit is clearly for high risk glands
- No benefit for low risk patients

24. Management
 Diagnosis requires :
- Drain amylase
- Clinical and imaging data
 NPO
 Supplementation nutrition (TPN/ NJ feeds)
 Antibiotics
 Procedure (Imaging guided)
 +/- Octreotide

25.  Re-exploration indicated in :
- Clinical decline
- Undrainable fistulas or abscesses
- Suspicion of pancreatico-jejunal anastomotic
dehiscence

26. Management of pancreatico-jejunal
dehiscence using bridge technique

27. Delayed gastric emptying
 Incidence : 6 – 50 %
 Defined by ISGPS

28. Preventive measures
 DGE is multifactorial
 Etiology:
- Decrease in plasma motilin following duodenal
resection
- Loss of vagal innervation to pylorus and antrum
- Relative devascularisation of antrum

29. Surgery advised :
 Pylorus preserving pancreaticoduodenectomy shown
to be advantageous in some studies but others
found the opposite.
 Currently NO clear better technique
 Other surgeons advise pylorus preserving
pancreaticoduodenectomy with pyloromyotomy

30. RETROCOLIC versus ANTEROCOLIC
gastro/duodeno – jejunostomy
 Retrocolic approach – 50 %
 Anterocolic – 5 %

31. Use of promotility agents
 Erythromycin - 37% reduction in incidence of DGE
 Metoclopramide : commonly used

32. Management of DGE
 NPO
 NG tube
 Nutritional rehabilitation ( TPN/ FJ feeds)
 Rule out intra-abdominal collections / POPF

33. Thank-
you